Provider Demographics
NPI:1124220744
Name:MANTRI, KSHITIJ O (R PH)
Entity Type:Individual
Prefix:MR
First Name:KSHITIJ
Middle Name:O
Last Name:MANTRI
Suffix:
Gender:M
Credentials:R PH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1510 PENTON MEWS
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320-2984
Mailing Address - Country:US
Mailing Address - Phone:757-410-2387
Mailing Address - Fax:
Practice Address - Street 1:525 W 21ST ST
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23517-1985
Practice Address - Country:US
Practice Address - Phone:757-625-6073
Practice Address - Fax:757-625-2494
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202206811183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist